Case Report Orthodontic Traction of Impacted Canine Using...

Case ReportOrthodontic Traction of Impacted Canine Using Cantilever

Claacuteudia Nakandakari1 Joatildeo Roberto Gonccedilalves1 Daniel Serra Cassano2

Taiacutesa Boamorte Raveli1 Jonas Bianchi1 and Dirceu Barnabeacute Raveli1

1Araraquara School of Dentistry Universidade Estadual Paulista (UNESP) Rua Humaita 1680 14801-90 Araraquara SP Brazil2Private Practice Avenida Doutor Gastao Vidigal 295 14802-408 Araraquara SP Brazil

Correspondence should be addressed to Dirceu Barnabe Raveli dravelifoarunespbr

Received 25 May 2016 Accepted 17 July 2016

Academic Editor Jose Lopez-Lopez

Copyright copy 2016 Claudia Nakandakari et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

The impaction of the maxillary canines causes relevant aesthetic and functional problems The multidisciplinary approach to theproper planning and execution of orthodontic traction of the element in question is essential Many strategies are cited in theliterature among them is the good biomechanical control in order to avoid possible side effects The aim of this paper is to presenta case report in which a superior canine impacted by palatine was pulled out with the aid of the cantilever on the SegmentedArch Technique (SAT) concept A 147-year-old female patient appeared at clinic complaining about the absence of the upper rightpermanent canine The proposed treatment prioritized the traction of the upper right canine without changing the occlusion andaesthetics For this it only installed the upper fixed appliance (Roth with slot 0018) opting for SAT in order to minimize unwantedside effectsThe use of cantilever to the traction of the upper right canine has enabled an efficient and predictable outcome becauseit is of statically determined mechanics

1 Introduction

Facial harmony is directly associated with the presence ofcanines in the dental arch which are important for stableocclusion [1] However tooth impaction can be one of the fac-tors responsible for the aesthetic and functional imbalanceIn particular the incidence of impaction of the upper caninesranges from 1 to 3 [2] Some etiological factorsmay justifythe retention andor impaction of the canine as the long paththat runs to its full eruption associated with the fact that isthe last tooth to erupt in chronological order besides geneticfactors atresic arcade trauma and consequences of systemicdiseases [1 3]

The impaction of maxillary canines occurs most fre-quently by palatine (85 against 15 in the buccal region)For a correct diagnosis and development of the treatmentplan it is essential to define the tooth location Thus it isessential to perform a detailed clinical examination associ-ated with radiographic andor computed tomography Clini-cal signs observed in cases of impaction are prolonged reten-tion of deciduous canine delayed eruption of the permanentcanine and depending on the position of the canine included

absence of vestibular bulging presence of palatal bulging anddistal slope of the maxillary lateral incisor crown and maypresent or not midline deviation [4]

The orthodontic treatment should be started as soon aspossible to avoid secondary problems [5] One of the mostsuitable procedures is orthodontic traction and its success isdirectly linked to the management of side effects Thereforebiomechanical knowledge is required to choose an idealsystem of forces for each intended movement [6]

The Segmented Arch Technique (SAT) consists in thedental arch segmentation for the consolidation of teeth inactive units and a passive unit (anchor) being designed byCharles Burstone in 1962 This technique can be applied tothe cantilever which is a device used for dental traction beingmade from titanium and molybdenum alloy (TMA) wire Alever arm inserted into a tube (anchorage unit) is connectedto an active unit (impacted canine) tieding to a free endTo increase system flexibility helicoids can be made close tothe fixed end The anchor block allows obtaining maximumstability of the posterior segment through the transpalatalarch (TPA) use which reduces undesirable effects [7 8]

Hindawi Publishing CorporationCase Reports in DentistryVolume 2016 Article ID 4386464 6 pageshttpdxdoiorg10115520164386464

2 Case Reports in Dentistry

(a) (b) (c)

(d) (e) (f)

Figure 1 Initial documentation profile photo (a) frontal photo (b) frontal photo with smile (c) intraoral photos right (d) frontal (e) andleft side (f)

Figure 2 Initial documentation study models showing a suitable arch shape and a good occlusal relationship

The aim of this paper is to present a case in which theupper canine impacted by palatine was pulled out with can-tilever aid in SAT concept in order tominimize the side effectsand increase the effectiveness of treatment

2 Case Report

A 147-year-old female patient appeared at clinic complainingabout the absence of the upper right permanent canineClinical examination showed symmetrical and proportionalface straight and harmonious profile passive lip closuresuitable smile line (Figures 1(a)ndash1(c)) AngleClass I occlusionmatching media lines normal overjet and overbite mixed

dentition with presence of the element 53 and the absence ofits successor 13 (Figures 1(d)ndash1(f)) The models confirm theocclusion in Angle Class l with parabolic arches and suitableoverjet and overbite (Figure 2)Through Clark technique thepalatal position of the canine was observed (Figure 3)

The proposed treatment prioritized the traction of theupper right canine without changing the occlusion andaesthetics For this it only installed the upper fixed appliance(Roth with slot 0018) opting for SAT in order to minimizeunwanted side effects After arch alignment and levelingthe anchorage unit was composed of a stainless steel arch(001710158401015840 times 002510158401015840) passing passively on all upper teeth exceptfor the canine

Case Reports in Dentistry 3

(a) (b)

(c)

Figure 3 Initial documentation exams imaging for diagnosis of impacted canine (a) and (b) are periapical radiographs with Clark technique(note that in (b) the tooth moved distally indicating its position by palatal) red arrow indicates the impacted tooth (c)

(a) (b)

Figure 4 Intraoral photographs Access to the impacted tooth through open surgery (a) The arrow points to the cantilever made from thetranspalatal arch extension cantilever in TMA coupled to the auxiliary band tube (b)

A modified Transpalatal Arch (TPA) with a stretchedarm at traction side was used At the end of this arm theextrusion force directed to impacted tooth was applied (Fig-ure 4) After mounting of the anchoring system the patientunderwent surgery for bonding orthodontic button Firstlythe closed technique was held to access the tooth Howeverthe accessory became unglued during traction and an opentunnel surgery was performed to guide the tooth trajectorywith an orthodontic bracket placed on the exposed crown

(Figure 4(a)) [9 10] A second cantilever made with TMAwire (001710158401015840 times 002510158401015840) was coupled by buccal to maximizethe biomechanics effects (Figure 4(b))

After traction controlled with the aid of cantilevers (Fig-ures 5(a) and 5(b)) the final positioning of impacted toothwas performed using a rectangular rigid steel wire (001710158401015840 times002510158401015840) containing a bypass for canine region Thus a roundwire of NiTi (0016) was added to the system of forcescausingminimal side effects and helping the canine to achieve


(a) (b)

(c)

Figure 5 Intraoral photographs Mechanism of action of the two cantilevers acting together (a) Removal of the transpalatal arch andcantilever coupled to the tube (b) Bypass in the region of upper right canine and round wire assisting in the mechanical forces (c)

Figure 6 Intraoral photos after 2 months of using the NiTi wire (0016)

the optimum position (Figure 5(c)) In Figure 6 the resultafter 2 months of NiTi wire use is observed

Figure 7 shows the end result of orthodontic treatmentThe mechanics have remained very punctual without sideeffects preserving the initial characteristics of the patient Inthe radiographic evaluation (Figure 8) the normality of toothpositions is noted in addition to satisfactory standard facial

3 Discussion

The permanent maxillary canines have significant incidenceof impaction being the most affected teeth after the thirdmolars The impaction of the canine is more common inthe maxilla palatally with unilateral trend It is three timesmore common in females and occurs even when there is thepresence of enough space to align the arch [11]

In this case ectopic position and exaggerated horizontalinclination of canine resulted in its impaction The diagnosis

was confirmed based on radiographic evaluation No historyof trauma or family report

Based on the initial analysis of the impacted tooth posi-tion treatment prioritized three orthodontic movementsextrusion verticalization and vestibularization Initially thecantilever was activated to verticalize and expose the toothcrown in the oral environment by applying a force with acomponentmainly extrusive In the vestibularmovement thecanine was displaced towards the arc and at extrusion thecantilever has leveled the canine [12] Thus the function hasbeen established besides position and aesthetic tooth in theocclusion at the same time the integrity of the periodontiumand surrounding structures was maintained [13]

In this clinical case the SAT has enabled applying biome-chanical principles to minimize the side effects generatedby orthodontic appliances regardless of patient cooperationSAT is particularly suitable for working with statically deter-mined force systems mild and constant avoiding unnec-essary and unpredictable movements [7 12 14] Although


Figure 7 Photos immediately after removal of the appliance

(a) (b)

Figure 8 Final radiographs In panoramic radiography good positioning of all erupted teeth and parallelism of roots are observed (a) inteleradiography it is noted good maxillomandibular relationship as well as between the upper and lower incisors (b)

it requires more clinical time and the segmented handlespromote certain discomfort to the patient the SAT is animportant tool for the orthodontist when continuous archtechniques are limited to control side effects and the desiredresult

4 Conclusion

The use of Segmented Arch Technique to traction of theupper right canine has enabled an efficient and predictableoutcome minimizing side effects in orthodontic arch

Competing Interests

The authors declare that they have no competing interests

References

[1] S E Bishara and D Ortho ldquoImpacted maxillary caninesa reviewrdquo American Journal of Orthodontics and DentofacialOrthopedics vol 101 no 2 pp 159ndash171 1992

[2] S F Dachi and F V Howell ldquoA survey of 3874 routine full-mouth radiographs I A study of retained roots and teethrdquoOralSurgery Oral Medicine Oral Pathology vol 14 no 8 pp 916ndash924 1961

[3] M A P Maahs and T B Berthold ldquoEtiologia diagnostico etratamento de caninos superiores permanentes impactadosrdquoRevista deCienciasMedicas e Biologicas vol 3 no 1 pp 130ndash1382004

[4] CA Frank andM Long ldquoPeriodontal concerns associatedwiththe orthodontic treatment of impacted teethrdquoAmerican Journal


of Orthodontics and Dentofacial Orthopedics vol 121 no 6 pp639ndash649 2002

[5] J N Elefteriadis and A E Athanasiou ldquoEvaluation of impactedcanines by means of computerized tomographyrdquo The Interna-tional Journal of Adult Orthodontics and Orthognathic Surgeryvol 11 no 3 pp 257ndash264 1996

[6] N Cohenca J H Simon A Mathur and J M Malfaz ldquoClinicalindications for digital imaging in dento-alveolar trauma Part 2root resorptionrdquo Dental Traumatology vol 23 no 2 pp 105ndash113 2007

[7] C J Burstone ldquoRationale of the segmented archrdquo AmericanJournal of Orthodontics vol 48 no 11 pp 805ndash822 1962

[8] L GMMaiaM LMMaia AWMachado A CMonini andL G Gandini Junior ldquoOtimizacao do tracionamento do caninoimpactado pela tecnica do arco segmentado relato de casoclınicordquo Revista Clınica de Ortodontia Dental Press vol 9 no 1pp 61ndash68 2010

[9] A Crescini T Baccetti R Rotundo E A Mancini and GP Prato ldquoTunnel technique for the treatment of impactedmandibular caninesrdquo International Journal of Periodontics andRestorative Dentistry vol 29 no 2 pp 213ndash218 2009

[10] D Smailiene A Kavaliauskiene I Pacauskiene E Zasci-urinskiene and K Bjerklin ldquoPalatally impacted maxillarycanines choice of surgical-orthodontic treatment method doesnot influence post-treatment periodontal status A controlledprospective studyrdquo The European Journal of Orthodontics vol35 no 6 pp 803ndash810 2013

[11] G Richardson and K A Russell ldquoA review of impacted perma-nentmaxillary cuspids diagnosis and preventionrdquo Journal of theCanadian Dental Association vol 66 no 9 pp 497ndash501 2000

[12] S G F R Caldas A A Ribeiro H Simplıcio and A WMachado ldquoSegmented arch or continuous arch technique Arational approachrdquoDental Press Journal of Orthodontics vol 19no 2 pp 126ndash141 2014

[13] K Jarjoura P Crespo and J B Fine ldquoMaxillary canine impac-tions orthodontic and surgical managementrdquo Compendium ofContinuing Education inDentistry vol 23 no 1 pp 23ndash26 2002

[14] M T Sakima P R T Sakima T Sakima J L G Gandini andA Santos-Pinto ldquoTecnica de arco segmentado de BurstonerdquoRevista Dental Press de Ortodontia e Ortopedia Facial vol 5 no2 pp 91ndash115 2000

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(a) (b) (c)

(d) (e) (f)

Figure 1 Initial documentation profile photo (a) frontal photo (b) frontal photo with smile (c) intraoral photos right (d) frontal (e) andleft side (f)

Figure 2 Initial documentation study models showing a suitable arch shape and a good occlusal relationship

The aim of this paper is to present a case in which theupper canine impacted by palatine was pulled out with can-tilever aid in SAT concept in order tominimize the side effectsand increase the effectiveness of treatment

2 Case Report

A 147-year-old female patient appeared at clinic complainingabout the absence of the upper right permanent canineClinical examination showed symmetrical and proportionalface straight and harmonious profile passive lip closuresuitable smile line (Figures 1(a)ndash1(c)) AngleClass I occlusionmatching media lines normal overjet and overbite mixed

dentition with presence of the element 53 and the absence ofits successor 13 (Figures 1(d)ndash1(f)) The models confirm theocclusion in Angle Class l with parabolic arches and suitableoverjet and overbite (Figure 2)Through Clark technique thepalatal position of the canine was observed (Figure 3)

The proposed treatment prioritized the traction of theupper right canine without changing the occlusion andaesthetics For this it only installed the upper fixed appliance(Roth with slot 0018) opting for SAT in order to minimizeunwanted side effects After arch alignment and levelingthe anchorage unit was composed of a stainless steel arch(001710158401015840 times 002510158401015840) passing passively on all upper teeth exceptfor the canine


(a) (b)

(c)


(a) (b)






(a) (b)

(c)





3 Discussion








(a) (b)



4 Conclusion


Competing Interests


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Biomaterials












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(c)





3 Discussion








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4 Conclusion


Competing Interests


References
























Biomaterials












Journal of




















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(c)





3 Discussion








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4 Conclusion


Competing Interests


References
























Biomaterials












Journal of





















(a) (b)



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Competing Interests


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Biomaterials












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Case Report Orthodontic Traction of Impacted Canine Using...

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